SUBACUTE BACTERIAL ENDOCARDITIS and ANTIMICROBIAL PROPHYLAXIS

LCDR Marc E. Arena Comprehensive Dentistry NPDS Bethesda, MD

The Root of All Evil

Infective Endocarditis

Subacute Bacterial Endocarditis • microbial infection of heart valves or endocardium • infective endarteritis

Infective Endocarditis
Subacute Bacterial Endocarditis • 10-60 cases per million people per year • 80% of cases from patients with predisposing conditions

Infective Endocarditis
Causes • Rapid onsetStaphylococcus Aureus • Insidious onsetStreptococcus Viridans

Infective Endocarditis
• • • • • • • • SYMPTOMS Weakness Fatigue Weight loss Fever Chills Night sweats Anorexia Arthralgia

Infective Endocarditis
• • • • • • SIGNS Petechial Hemorrhages Linear Hemorrhages Osler Nodes Janeway Lesions Retinal Hemorrhages Heart Murmur

Infective Endocarditis

Outcome • Fatal 10-70% of cases

Infective Endocarditis
Complications Reinfection Congestive heart failure Renal Disease Cerebral Vascular Accident

• • • •

Conspiracy Theories

Endocarditis and Dentistry
Dental procedures produce a transient bacteremia: Streptococcus Viridans • S. Mutans • S. Mitis

Endocarditis and Dentistry
Risk of bacteremia from daily activities, homecare & eating 1000 times greater than risk from dental treatment Streptococcus Viridans • S. Mutans • S. Mitis

Endocarditis and Dentistry
Documentation • Anecdotal evidence • In vitro studies

Double blind placebo study not likely

Ideal Antimicrobial Prophylaxis
• Benefits outweigh risks • Antibiotics in blood prior to bacterial dissemination • Loading dose • Antibiotics specifically effective • Antibiotics time specific • Cheap and easy to use

Antimicrobial Recommendations
ADA/AHA (August 1997) ADA/AAOS (July 1997)

Indications for Prophylaxis
Cardiac Conditions (table 1) HIGH RISK • Prosthetic heart valves • Previous endocarditis • Congenital heart disease • Pulmonary shunts

Indications for Prophylaxis
Cardiac Conditions (table 1) MODERATE RISK
• Congenital cardiac malformations • Acquired valvar dysfunction • Hypertrophic cardiomyopathy • MVP with regurgitation

Indications for Prophylaxis
OTHER CONDITIONS • Rheumatic heart disease • Systemic lupus erythematosus • Marfan’s Syndrome • Prior history of drugs to treat obesity
– Fenfluramine – Phentermine – Dex-fenfluramine

Antimicrobial Prophylaxis Not Recommended
Cardiac Conditions • Isolated secundum atrial septal defect • Repaired atrial septal defect, ventricular septal defect or patent ductus arteriousus • Previous CABG • MVP without valvar regurgitation

Antimicrobial Prophylaxis Not Recommended
Cardiac Conditions
• Physiologic, functional or innocent heart murmurs • Previous Kawasaki disease without valvar dysfunction • Previous Rheumatic fever without valvar dysfunction • Cardiac pacemakers and implanted defibrillators

Antimicrobial Prophylaxis Not Recommended
Other than Cardiac Conditions • Neutropenic patient • Diabetic patient • Asplenic patient • End stage renal disease • Transplant patient • HIV patient

Antimicrobial Prophylaxis Not Recommended
Other than Cardiac Conditions • Total joint replacement (after two years) • Other implanted devices
– – – – – Cerebrospinal fluid shunts Intravascular access device Penile implant Breast implants Intraocular implants

Dental Procedures Associated with Bacteremias
• Periodontal Procedures
– – – – – surgery scaling and root planing probing and recall maintenance subgingival placement of antibiotic fibers or strips Prophylactic cleaning where bleeding is anticipated

Dental Procedures Associated with Bacteremias
• • • • • • Extractions Implant placement Reimplantation of avulsed teeth Endodontics beyond the apex Placement of orthodontic bands Intraligamentary injections

Dental Procedures NOT Associated with Bacteremias
• • • • • Restorative dentistry Local anesthetic injections Intracanal endodontics and post placement Rubber dams Suture removal

Dental Procedures NOT Associated with Bacteremias
• Removal of prosthodontic or orthodontic appliances • Oral impressions • Fluoride treatments • Radiographs • Orthodontic appliance adjustment • Shedding of primary teeth

Antimicrobial Prophylaxis Regimens ADA/AHA
Standard general prophylaxis: • Amoxicillin • Adults: 2.0 grams; Children: 50mg/kg orally 1 hour before procedure

Antimicrobial Prophylaxis Regimens ADA/AHA
Unable to take oral medications: • Ampicillin • Adults: 2.0 grams IM or IV; Children: 50mg/kg IM or IV within 30 min before procedure

Antimicrobial Prophylaxis Regimens ADA/AHA
Allergic to penicillin:

• Clindamycin

• Adults: 600mg; Children: 20mg/kg orally 1 hour before procedure

Antimicrobial Prophylaxis Regimens ADA/AHA
Allergic to penicillin: • Cephalexin or cefadroxil
*not recommended for use in patients with immediatetype hypersensitivity to PCN

• Adults: 2.0 grams; Children: 50mg/kg orally 1 hour before procedure

Antimicrobial Prophylaxis Regimens ADA/AHA
Allergic to penicillin:

• Azithromycin or clarithromycin

• Adults: 500mg; Children: 15mg/kg orally 1 hour before procedure

Antimicrobial Prophylaxis Regimens ADA/AHA
Allergic to penicillin and unable to take oral medications: • Clindamycin • Adults: 600mg; Children: 20mg/kg IV within 30 min before the procedure

Antimicrobial Prophylaxis Regimens ADA/AHA
Allergic to penicillin and unable to take oral medications: • Cefazolin * not recommended in
patients with severe PCN allergy

• Adults: 1.0gram; Children: 25mg/kg IV or IM within 30 min before the procedure

Antimicrobial Prophylaxis Regimens ADA/AAOS
Not allergic to penicillin and able to take oral medications: • Cephalexin, cephradine or amoxicillin

• Adults: 2.0grams orally 1 hour before the procedure

Antimicrobial Prophylaxis Regimens ADA/AAOS
Not allergic to penicillin and unable to take oral medications:

• Cefazolin • Ampicillin

• Adults: 1.0gram IV or IM 1 hour before the procedure • Adults: 2.0grams IV or IM 1 hour before the procedure

Antimicrobial Prophylaxis Regimens ADA/AAOS
Allergic to penicillin and able to take oral medications: • Clindamycin
• Adults: 600mg orally 1 hour before the procedure

Antimicrobial Prophylaxis Regimens ADA/AAOS
Allergic to penicillin and unable to take oral medications: • Clindamycin
• Adults: 600mg IV 1 hour before the procedure

Recommendations
• Screen all patients • Excellent homecare • Homecare mastered before routine treatment

Recommendations
• Expeditious treatment • 7-14 days between appointments

Recommendations
• Patients already taking antibiotics need a different antibiotic • Prerinse (not gingival irrigation) • Edentulous patients

Recommendations
If unexpected bleeding occurs institute antibiotic prophylaxis within 2 hours!

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